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| __NOTOC__ | | __NOTOC__ |
| {{Cystitis}} | | {{Cystitis}} |
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| | {{CMG}} {{AE}} {{YD}} |
| | ==Overview== |
| | Preventative measures to avoid cystitis include abstinence from sexual activity, voiding after intercourse, use of barrier contraception during sexual intercourse, increasing fluid intake and frequency of urination, and use of [[estrogen]] (among post-menopausal women). Single-dose prophylactic antimicrobial therapy prior to sexual intercourse may be administered to patients who have recurrent episodes of cystitis that are associated with sexual activity. |
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| {{CMG}}; {{SCC}} {{AE}}{{AK}} | | ==Primary Prevention== |
| ==Prevention== | | The following preventative measures may reduce the risk of cystitis: |
| | <ref name="Raz-1993">{{Cite journal | last1 = Raz | first1 = R. | last2 = Stamm | first2 = WE. | title = A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. | journal = N Engl J Med | volume = 329 | issue = 11 | pages = 753-6 | month = Sep | year = 1993 | doi = 10.1056/NEJM199309093291102 | PMID = 8350884 }}</ref> |
| | *Abstinence from sexual activity |
| | *Voiding after every intercourse |
| | *Use barrier contraception and avoiding spermicides |
| | *Increasing the intake of fluids and the frequency of urination |
| | *Use of topical estrogen among post-menopausal women |
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| ===Non-antimicrobial approach===
| | The use of cranberry to prevent cystitis remains controversial. Cranberry is thought to prevent the adherence of uropathogens to urothelial cells, but its benefit is yet to be proven.<ref>{{Cite journal |last1 = Hooton | first1 = TM. | title = Clinical practice. Uncomplicated urinary tract infection. | journal = N Engl J Med | volume = 366 | issue = 11 | pages = 1028-37 | month = Mar | year = 2012 |doi = 10.1056/NEJMcp1104429 | PMID = 22417256 }}</ref> |
| *Though it is difficult to apply, but abstinence or reduce frequency of sexual intercourse (which is the strongest risk factor for UTI)is a good method to reduce the risk of infection.
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| *Increasing the intake of fluids may allow frequent urination to flush the bacteria from the bladder. Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during intercourse. Refraining from urinating for long periods of time may allow bacteria time to multiply, so frequent urinating may reduce risk of cystitis in those who are prone to urinary tract infections.
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| *Using contraception methods other than spermicides especially with diaphragm or spermicide-coated condoms, because they alter normal vaginal flora allowing pathogens to colonize.
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| *Topical estrogen for postmenopausal women maintains normal vaginal flora and reduces risk of UTIs.<ref name="Raz-1993">{{Cite journal | last1 = Raz | first1 = R. | last2 = Stamm | first2 = WE. | title = A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. | journal = N Engl J Med | volume = 329 | issue = 11 | pages = 753-6 | month = Sep | year = 1993 | doi = 10.1056/NEJM199309093291102 | PMID = 8350884 }}</ref>
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| *Cranberry juice, capsules or tablets:although it inhibits uropathogen from adherence to uroepithelial cells, but studies revealed no benefit from using cranberry juice.<ref name="Jepson-2012">{{Cite journal | last1 = Jepson | first1 = RG. | last2 = Williams | first2 = G. | last3 = Craig | first3 = JC. | title = Cranberries for preventing urinary tract infections. | journal = Cochrane Database Syst Rev | volume = 10 | issue = | pages = CD001321 | month = | year = 2012 | doi = 10.1002/14651858.CD001321.pub5 | PMID = 23076891 }}</ref>21148516
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| *D-mannose theoretically inhibits [[E.Coli=]] adherence to oruepithelium, but no studies support the benefit or effectiveness.
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| Recommend abstinence or reduction in frequency of intercourse Sexual intercourse is the strongest risk factor for uncomplicated UTIs;
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| often this behavioral strategy is not feasible
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| If spermicides are used, recommend changing to another method
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| for contraception or prevention of infection
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| Spermicide use, including use of spermicide-coated condoms, is a
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| strong risk factor, especially if used with a diaphragm; spermicides
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| alter the vaginal flora and favor the colonization of uropathogens
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| Recommend that patient urinate soon after intercourse, drink
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| fluids liberally, not routinely delay urination, wipe front to
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| back after defecation, avoid tight-fitting underwear, avoid
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| douching
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| In case–control studies, none of these strategies have been shown
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| to be associated with a reduced risk of recurrent UTIs, and none
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| have been studied prospectively; however, it is reasonable to
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| suggest them to the patient, since they pose a low risk and might
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| be effective
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| Biologic mediators
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| Cranberry juice, capsules or tablets Biologic plausibility is based on the inhibition of uropathogen adherence
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| to uroepithelial cells; clinical data supporting a protective
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| effect have been limited by design flaws40; a recent randomized,
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| placebo-controlled trial showed no benefit from cranberry juice41
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| Topical estrogen In some postmenopausal women, topical estrogen normalizes the
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| vaginal flora and reduces the risk of recurrent UTIs42; oral estrogens
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| are not effective
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| Adhesion blockers (D-mannose, available in health-food stores
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| and online, is occasionally used as preventive therapy)
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| UTIs caused by E. coli are initiated by adhesion of the bacteria to mannosylated
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| receptors in the uroepithelium by means of FimH adhesin
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| located on type 1 pili; theoretically, mannosides could block adhesion;
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| however, D-mannose has not been evaluated in clinical trials
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| Strategy Comments
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| Self-diagnosis and self-treatment
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| First-line antimicrobial regimen is prescribed for future use;
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| patient
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| is advised to take it at onset of UTI symptoms
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| This is not a preventive strategy. Women with previously diagnosed cystitis
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| can accurately self-diagnose subsequent cystitis in more than 85 to 95%
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| of cases and can successfully treat themselves43; higher patient satisfaction
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| with this strategy than with traditional visits to provider for UTI
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| symptoms and less antimicrobial exposure than with continuous antimicrobial
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| prophylaxis; should be reserved for motivated women with
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| previous culture-confirmed cystitis who will comply with the treatment
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| regimen; urine culture should be obtained periodically before treatment
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| to confirm presence of UTI and drug susceptibilities
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| Antimicrobial prophylaxis†
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| Postcoital antimicrobial prophylaxis: single dose of antimicrobial
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| agent as soon as feasible after intercourse
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| Nitrofurantoin, 50–100 mg‡
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| TMP-SMX, 40 mg and 200 mg or 80 mg and 400 mg§
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| TMP, 100 mg§
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| Cephalexin, 250 mg‡
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| In a placebo-controlled trial, the rate of recurrent cystitis with postcoital
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| TMP-SMX, 40 mg and 200 mg, was 0.3 episodes per patient-year, vs.
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| 3.6 with placebo (a 92% reduction)44; can be used if UTIs are temporally
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| related to coitus; absence of bacteriuria should first be confirmed by
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| negative results on urine culture; results in less antimicrobial exposure
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| than with continuous prophylaxis; fluoroquinolones (e.g., ciprofloxacin,
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| 125 mg) are highly effective but are not recommended§
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| Continuous antimicrobial prophylaxis: daily bedtime dose
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| (except fosfomycin; see below)
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| Nitrofurantoin, 50–100 mg‡
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| TMP-SMX, 40 mg and 200 mg (3 times weekly is also effective)§
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| TMP, 100 mg§
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| Cephalexin, 125–250 mg‡
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| Fosfomycin, 3-g sachet every 10 days‡45
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| Randomized, placebo-controlled trials have shown a reduction in cystitis
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| recurrences of approximately 95%; side effects are common (e.g., rash,
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| yeast vaginitis); absence of bacteriuria should first be confirmed by negative
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| results on urine culture; a 6-month trial is recommended, then treatment
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| is discontinued and the patient observed; about 50% of patients
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| have a reversion to the previous pattern of recurrences of cystitis24; if recurrences
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| continue, prophylaxis may be restarted; rare toxic effects of
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| long-term exposure to nitrofurantoin include pulmonary hypersensitivity,
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| chronic hepatitis, and peripheral neuropathy; fluoroquinolones (e.g.,
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| ciprofloxacin, 125 mg) are highly effective but not recommended§; antimicrobial
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| resistance in colonizing strains or breakthrough infections are
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| reported in some studies
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| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
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